Provider Demographics
NPI:1790403780
Name:RUTKOWSKI, ELLY KUMIKO BASIA (AUD)
Entity Type:Individual
Prefix:
First Name:ELLY
Middle Name:KUMIKO BASIA
Last Name:RUTKOWSKI
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 WOODRUFF PLACE EAST DR
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46201-1917
Mailing Address - Country:US
Mailing Address - Phone:317-607-2600
Mailing Address - Fax:
Practice Address - Street 1:4090 BRIARGATE PKWY
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80920-7815
Practice Address - Country:US
Practice Address - Phone:719-305-1234
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist